Male Pathology - Testis

Question 1

Answer 1

Question 2

What is cryptorchidism?

Answer 2

When one or both testes do not descend properly into the scrotum

hCG dependent process

May be found in the inguinal canal, the upper scrotum, or within the abdomen

Infertility is the most frequent complication

Germ cell tumors 4-10 times more likely

Question 4

What are some common causes of epididymitis?

Answer 4

UTI (>35)

STI (<35)

Gonorrhea, Chlamydia, TB, E coli, Pseudomonas

Question 5

What sign is positive with epidiymitis?

Answer 5

Prehn’s sign

Elevation of the scrotum decreases pain

Question 6

What are some common causes of orchitis?

Question 7

Answer 7

Acute Epidiymitis

Question 8

Twisting of the spermatic cord that cutts off the venous/arterial blood supply

Answer 8

Torsion of the Testis

Question 9

What are some predisposing factors to torsion of the testes?

Answer 9

Violent movement or physical trauma (most common)

Cryptorchid testis

Atrophy of testis

Question 10

What are some clinical findings with torsion of the testis?

Answer 10

Sudden onset testicular pain

Negative Prehn’s sign

Needs surgery to prevent hemorrhagic infaction of the testis

Question 11

Risk factors for testicular cancer

Question 12

What are the three types of intratubular germ cell neoplasias?

Answer 12

Seminoma (40%, age 40s)

Mixed (30%)

Non-seminomatous (30%) – Embryonal ca., yolk sac tumor, choriocarcinoma, teratoma (mature or immature) age 20-30s

Question 13

What percent of patients with ITGCN develop an invasive germ cell tumor within 7 years?

Answer 13

>70%

Involvement is pathy and 40% are bilateral

Two 3mm testicular biopsies will identify the majority of patients with ITGCN.

Spermatogenesis is absent in involved tubules - cells are atypical with nuclear enlargement and large nucleoi

DNA content is aneuploid; contains isochromosome 12p, like seminoma

Question 14

Answer 14

Red - Sertoli

Germ cells - Dark red

Question 15

Answer 15

ITGCN

Sertoli cells (red)

Germ cells (dark red)

Question 16

Answer 16

Seminoma

Mean patient age 40s

Arranged in solid nests separated by fibrous septa; lymphoid infiltrate

Question 17

Answer 17

Seminoma cells (almost whole area)

Vessel - invaded with seminoma cells

“Square” nuclear contours due to molding

Question 18

Markers for Seminoma

Answer 18

a-fetoprotein (AFP): usually normal

B-human chorionic gonadotropin (hCG): can be elevated

Question 20

What are non-seminomatous germ cell tumors sensitive to?

Answer 20

They are chemosensitive but not radiosensitivity

Question 21

What are the 4 types of non-seminomatous germ cell tumors?

Answer 21

Embryonal carcinoma

Yolk sac tumor

Choriocarcinoma

Teratoma (mature and immature)

Question 22

Answer 22

Embryonal carcinoma

Age 20-30s

Fleshy gray-white tumor with prominent necrosis

There is a solid pattern of embryonal carcinoma, which can simulate seminoma

Question 23

Answer 23

Cells of embryonal carcinoma are large with vesicular nuclei, prominent nucleoli, glandular structures

2nd most common germ cell tumor

Metastases in up to 40%

Serum AFP is normal

B-hCG is elevated in 60% of cases

Question 24

Most common germ cell tumor in infants/children - 90% are cured by orchiectomy

In adults – component of mixed germ cell tumor

Answer 24

Yolk Sac Tumor (endoermal sinus tumor)

Main tumor marker = elevated serum alpha-fetoprotein (AFP)

White to tan masses with myxoid and cystic changes

Question 25

Answer 25

Yolk Sac Tumor

Deposition of basement membrane material, and Schiller-Duval bodies are characteristic –> central vessel rimmed by loose connective tissue that in turn is lined by malignant epithelium, all within a cystic space

Question 26

Pure form - mean age of 20 months, in children, no metastases

In adults - mixed germ cell tumor and is identified in >50% of mixed tumors

Answer 26

Teratoma

Question 27

Immature vs Mature Teratoma

Answer 27

Mature = somatic-type tissues that can include intestine-type glands, respiratory epithelium, cartilage, muscle, squamous epithelium

Immature = immature neuroepithelium, blastema, carcinoid, or cellular stroma –> WORSE outcome

Question 28

Answer 28

Teratoma

Respiratory epithelium (left)

Fat cells (right)

Question 29

Metastases to brain or lungs

Serum B-hCG elevated

Poorer prognosis, but tumor is sensitive to chemotherapy

Multinucleated syncytiotrophoblastic cells and mononuclear cytotrophoblast or intermediate trophoblast

Stain hCG+

Answer 29

Choriocarcinoma

Question 30

Answer 30

Leydig cell tumor - clear cytoplasm, cells are not nested

Majority in adults (80%)

10-17% malignant

Unilateral with rare exceptions

Benign treated with orchiectomy

Malignant require retroperitoneal lymph node dissection

Question 31

Answer 31

Sertoli cell tumor – closely packed cords

<1% of testicular tumors

Malignant in 10% of cases

Estrogen production by the tumor can result in gynecomastia and impotence

Question 32

Answer 32

Lymphoma

Most common testis tumor over age 60

Usually result of secondary spread

20% bilateral

White to tan fleshy tumor - interstitial growth pattern with sparing of seminiferous tubules

Most are diffuse large cell types with a B-cell phenotype

Question 34

What is the most common tumor of the epididymis?

Answer 34

Adenomatoid tumor

May also be identified in tunica albuginea and spermatic cord

Question 35

Answer 35

Adenomatoid tumor

Circumscribed, gray-white

May extend into rete testis and testis

Always benign

Probably mesothelial origin

Question 36

What is the most common cause of scrotal swelling?

Answer 36

Hydrocele

Question 37

Answer 37

Vasitis Nodosa

Usually observed after vasectomy, blind end of transected vas deferens

Sperm-containing ductules that extend into stroma

Resembles invasive adenocarcinoma, but the prescence of sperm, chronic inflammation and lack of atypia.

Question 38

Answer 38

Metastases to the testis: #1 is prostate cancer